HomeMy WebLinkAbout1530A /�, n�pr p�}►� �j,�p ,
WORKERS'COMPENSAiION DEClARAfiOM �� APPLIC����� rVR PLUlY{D�f\i�3��n/Y1���; � � '
I hereby offirm that i have o<er�iEimte of consent lo nel! 20-0�26 DPW 6l87 ; � - ;' .^' : �
inwre,or o cerlificate ot Wo�kars'Compensotion Insuronce, 76A667A � �`- �'�
or a certified to�pys th1ereof(y`ec 3800,l C. r /� . COUNTY OF LOS ANGELES DEPT.OF.PUBUC WORKS
P�olity No�d����"" "Compony �tr���' �
Cerlified copy is hereby furnished. BUILDiNG
FOK APPLICANT TO FILL W(P{tINT OR TYPE) ADDRE55 i d z3 J�i U✓�
Certified copy is filed with the cov ry building insp ` �
iond�epsa�r�m,enf. ri1MBER fl%TUREORITEM � fEE ���rcY �,�.,F�+���r
Do1C�Sl�Appli nt WATERUOSEl NEAREST
CERTIFICASE OF E MP qN FROM WORKERS' � BATM TUB CROSS ST.
COMPE N INSURANCE � SHOWER OWNER d�)���?
(Thi��«fion no�d not � eompbbd.H t6o wark Inrolvad 6y Mpq
Ih�p�r�wN Fs for on�lwndred aellari(31DOf or I��a.) �_ LqVqTORY A��RE55 '
I cerfify 1M�at in the performonce of the wark far which this ��Ty TEt.NO. �
psrmil is issued,f sho11 nof employ any person in any monner SINK
so aa to become subject�o rhe Worker' ompenaotion la . � DISMWASHER COMRACTOR ps C�yt i
QOlNES WASHFR �� j
Daie � pplt[ ADDIiE55
NOTICE TO APPIICANT: ! af r making this eriifica�e of SWIMMINGPOOLRECEPiOR �
E■emption, you sho�l b ome sub'�ect to the Workers' - CITY � �^Q,. TEL N0. ��� �
Compensaffon provis�o the Labor Coda,you muif fofth- UWNSPRINKLERSYSTEM
with Comply wilh suc pravisions or this permit shall be STAT � � IIC. Y
LICENSE NO. � C1A55
de�med revoked. � ' WA7FRHEATER �
tICENSEO CONTRACTORS QECLARATIQN OISTRiCt NO. ESSED BY �
I heroby offirm thpf 1 am�iCanaed under provieions of Chapter 9 GAS 5YSSEM OUFlETS ��_ �
(commencing with S�ction 7000)of 6ivision 3 of!he B�aine�s - OUnEf50VER } '
and Profeuions Code,and my license'rs in full force and effect. � 5 PE 5YS1EM FINAI YALIOATION LL' �
oYG� onTe � �
License N�mber lic,Clas�
FlNAL �
Controctor � �'��� Date �9 Z' � BY O '
Q V !
'� 4 om exempt under Sec. a Y
8.8P.C.for�his reoson p{an cheGk fee
oa�Q. �t 5 3 Q A � _
PLUM8ING PERMIT ISSUING FEE$ #� �. • �rj �
SigtwWra � �� �� �
TOTAL FEE � �
Plan check applicant . i
SINGIE FAMILV `I+t 4 6 5 p !
HOME OWNFR-BUIl6ER UECLARATION Pk�me � ����S 9= q
I hmeby offirm that l am exempt from�he Controctor's Litense � "
Law for the following reoson(Seclion 7037.5, Business ond Address ��t ��$9 `
Professions Code): Ciry Tel.No.
❑ I,as owner oi the properry,will do ihe work ond�he 4
� 1
str�dure ia not intendad or offered for sale �SeUion i
7044,Business and Professions Codej. I
CONSTRUCTION IENDING AGENCY i
I hereby affirm that there i:a mnstruction lending agency for �
the performance of the work for which rhis permir is issued
(Sec 3097,Civ.C.). � ;
I
Lender's hlame I
Lender a Address �
1 cerlify that 1 hove read lhis appl�cafion and state fhol�he �
obove informafion ia corrett.I agree�o tomply with all County
ordinances and Staie fows reguVoting Pl�mbin9,ond he�eby
ou�honze repre�enlatives of ihis County to eNer upon the � � +
a6ov eMiOned p�opBrty for inspeCtion purposes.
� r2 SEE REVERSE fOR EXPIAFlATORY LANGUAGE �
Signature of Permi ee Dote �1
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